Hannah Royle
4 Oct 2021 · Coroner Karen Henderson · West Sussex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. non-compliant 111 service handling of disabled patients
“Both calls to the 111 service were significantly non-compliant; the call handlers did not correctly complete the algorithm, they did not take into consideration [the deceased]'s disabilities and inability to verbalise, they failed to recognise [the deceased] as a complex case requiring transfer to a more senior member of the 111 service despite [the deceased]'s parents providing sufficient information for that to be the case.”
2. lack of disability accommodation in 111 algorithm
“The 111 service does not have a sufficiently robust system to manage members of the public with underlying disabilities in that no accommodation is given for it in the completion of the algorithm.”
3. inadequate clinical advisor competence
“The skill and expertise of the 'clinical advisor' was wholly inadequate for her position as she had no contemporaneous or relevant experience in working in an emergency department as a nurse. She was also insufficiently robust in her assessment and understanding of [the deceased]'s condition when the call handler contacted her for advice.”
4. public misperception of 111 service capabilities
“Members of the public who contact the 111 are ill-informed with a real risk they are being misled over the role and capability of the 111 service. There is little clarity or understanding by the public that it is based on following and completing an algorithm by individuals who have no need for any qualification in health care and who will only receive a short training programme after they are employed.”
5. insufficiently discriminatory abdominal pain pathway
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The NHS pathway for 'Abdominal Pain' is insufficiently robust or sufficiently discriminatory to effectively deal with the myriad of potential symptoms associated with this complaint.”
Later report
“The inquest also examined East Kent Hospital's Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented”
Responses
2021-0327-Response-from-NHS-Digital_Published.pdf ↗· NHS Digital
2021-0327-Response-from-South-East-Coast-Ambulance-Service_Published.pdf ↗· Health Education England
Stated action · October 2021
“Our 111-service management team agree that this was a complex case and should have been transferred to a clinician. In order to ensure that call handlers fully understand the need to identify and refer such cases, the following actions have been taken: 1. Work has been undertaken on a focused area of learning known as a”
Stated action
“Key skills is the name given to core training delivered to all members of staff quarterly. The content varies according to job role and is based upon required system updates, clinical updates and learning from incidents and events. The next key skills for Health Advisors and Emergency Medical Advisors will include a section on dealing with calls from or about patients who have a learning disability.”
Stated action
“The handling of complex calls has been added to those core competencies and as such new Health Advisors and Emergency Medical Advisors will be required to demonstrate this as a competency moving forwards.”
Stated action · January 2022
“Our Head of Governance for 111 plans to publish a shared learning based on [the deceased]'s family's contacts with the 111 service before the end of January 2022.”
Stated action
“It is for NHS Digital to address the issue of how NHS Pathways accommodates patients with underlying disabilities.”
Stated action
“SECAmb does not specify a field of experience such as A&E or urgent care because the range of medical conditions and situations with which we deal on a daily basis is so wide. Experience in a wide range of disciplines in our clinical workforce in the 111 service is an advantage; a broad spectrum of experience in different clinical settings (e.g. cardiac, stroke, paediatrics, mental health) helps us to accommodate the extremely diverse needs of our patients.”